Animal Bite/Contact Report

Please provide as much information as possible.

Reported By

Email of Person Submitting Form

Phone Number

Address

City

Postal Code

Person Bitten/Scratched

Date of incident

Name of Person Bitten/Scratched

Phone Number of Person Bitten/Scratched

Email Address of Person Bitten/Scratched

Parent/Guardian Name (if applicable)

Address of Person Bitten/Scratched

City

Postal Code

Date of Birth

Gender

M

F

Weight (lb or kg)

Type of Exposure

Bite

Scratch

Other

Location of Wound on Body (i.e. left arm)

Animal Information

Type of Animal

Bat

Cat

Dog

Racoon

Other

Name of Animal (if known)

Animal Breed (if known)

Animal Colour

Animal Size

Incident Details

Animal Owner Information

Name of Animal Owner (if known)

Phone Number of Animal Owner

Email Address of Animal Owner

Address of Animal Owner

City

Postal Code

For Hospitals

Wound Care Provided

Yes

No

Rabies Immune Globulin Issued

Yes

No

Rabies Vaccine Issued

Yes

No

NOTE: Collection of information on this form is authorized under the Health Protection and Promotion Act RSO, 1990 CH 7, SECTIONS 5 and 31 for the purpose of controlling and reporting communicable diseases.

For more information, please contact our Health Protection and Investigation program at 519-575-4400.

Region of Waterloo Form

Animal Bite/Contact Report

Person Bitten/Scratched

Animal Information

Animal Owner Information

For Hospitals